Integrating anaesthesia and intensive care into the National Care Record

The National Care Record for England is planned to be deliveredas part of the National Programme for Information Technology(NPfIT) by the National Health Service Connecting for Health.It will be made up from a National Summary Care Record, LocalDetailed Care Records and from images in Picture Archiving andCommunication Systems. Full benefits for clinical care willonly come when there is true integration of the clinical recordssystems which enables rapid clinical decision support, a consistentuser interface, single entry of data items and analysis of informationacross the full spectrum of clinical care. Currently there arefew hospitals with fully electronic anaesthetic or criticalcare systems, and these are only partly linked to the hospitalsystems. This limits their benefit to patient care and healthcare staff. As NPfIT is being mandated for all hospitals inEngland it is essential to consider now how the next generationof anaesthetic and intensive care systems will integrate withit.     

Review of ethics in paediatric anaesthesia: intensive care issues

This is the third of a series of three articles examining the recent changes in the law in relation to ethics and the practice of paediatric anaesthesia. The review covers, in a practical question and answer format, the topics of consent, research, intensive care issues and organ donation in children.     

Oxygen sensing,anaesthesia and critical care: a narrative review

In 2019, the scientists who discovered how cells sense and adapt to oxygen availability were awarded the Nobel Prize. This elegant sensing pathway is conserved throughout evolution, and it underpins the physiology and pathology that we, as clinicians in anaesthesia and critical care, encounter on a daily basis. The purpose of this review is to bring hypoxia-inducible factor, and the oxygen-sensing pathway as a whole, to the wider clinical community. We describe how this unifying mechanism was discovered, and how it orchestrates diverse changes such as erythropoiesis, ventilatory acclimatisation, pulmonary vascular remodelling and altered metabolism. We explore the lessons learnt from genetic disorders of oxygen sensing, and the wider implications in evolution of all animal species, including our own. Finally, we explain how this pathway is relevant to our clinical practice, and how it is being manipulated in new treatments for conditions such as cancer, anaemia and pulmonary hypertension.     

Neuromuscular disorders: relevance to anaesthesia and intensive care

Neuromuscular diseases are relatively rare, but it is important for both anaesthetists and intensivists to have a working knowledge of the common diseases as they may complicate general anaesthesia and result in neurogenic respiratory failure. The most common neurological condition seen in the intensive care unit is that of critical illness neuropathy; this subject is covered elsewhere in the journal. The diseases most commonly encountered in general anaesthetic practice include motor neurone disease, Guillain-Barré syndrome, botulism, myasthenia gravis and the muscular dystrophies.     

Neuromuscular disorders: relevance to anaesthesia and intensive care

Although relatively rare, neuromuscular disease is important to both anaesthetists and intensivists as it may complicate general anaesthesia and result in neurogenic respiratory failure. The most common diseases that will be encountered in a general anaesthetic practice include motor neurone disease, Guillain–Barré syndrome, botulism, myasthenia gravis and the muscular dystrophies. The clinical features and anaesthetic implications for these conditions are discussed.     

Neuromuscular disorders: relevance to anaesthesia and intensive care

Neuromuscular diseases are relatively rare but it is important for both anaesthetists and intensivists to have a working knowledge of the common diseases, as they may complicate general anaesthesia and result in neurogenic respiratory failure. The most common neurological condition seen in the intensive care unit is that of critical illness neuropathy; this subject is covered elsewhere in the journal. The diseases most commonly encountered in general anaesthetic practice include motor neurone disease, Guillain-Barré syndrome, botulism, myasthenia gravis and the muscular dystrophies.     

Neuromuscular disorders: relevance to anaesthesia and intensive care

Although relatively rare, patients with neuromuscular disease do present for anaesthesia and intensive care management. Although a large number of neuromuscular diseases exist, general anaesthetists or intensive care consultants are most likely to encounter the more common conditions such as motor neurone disease, Guillain–Barré syndrome, myasthenia gravis and the muscular dystrophies. This article outlines the management of these conditions.     

Non-technical skills in the intensive care unit

In high-risk industries such as aviation, the skills not relateddirectly to technical expertise, but crucial for maintainingsafety (e.g. teamwork), have been categorized as non-technicalskills. Recently, research in anaesthesia has identified anddeveloped a taxonomy of the non-technical skills requisite forsafety in the operating theatre. Although many of the principlesrelated to performance and safety within anaesthesia are relevantto the intensive care unit (ICU), relatively little researchhas been done to identify the non-technical skills requiredfor safe practice within the ICU. This review focused upon criticalincident studies in the ICU, in order to examine whether thecontributory factors identified as underlying the critical incidents,were associated with the skill categories (e.g. task management,teamwork, situation awareness and decision making) outlinedin the Anaesthetists' Non-technical Skills (ANTS) taxonomy.We found that a large proportion of the contributory factorsunderlying critical incidents could be attributed to a non-technicalskill category outlined in the ANTS taxonomy. This is informativeboth for future critical incident reporting, and also as anindication that the ANTS taxonomy may provide a good startingpoint for the development of a non-technical skills taxonomyfor intensive care. However, the ICU presents a range of uniquechallenges to practitioners working within it. It is thereforenecessary to conduct further non-technical skills research,using human factors techniques such as root-cause analyses,observation of behaviour, attitudinal surveys, studies of cognition,and structured interviews to develop a better understandingof the non-technical skills important for safety within theICU. Examples of such research highlight the utility of thesetechniques.     

The impact of COVID-19 on anaesthesia and critical care services in the UK: a serial service evaluation*

Between October 2020 and January 2021, we conducted three national surveys to track anaesthetic, surgical and critical care activity during the second COVID-19 pandemic wave in the UK. We surveyed all NHS hospitals where surgery is undertaken. Response rates, by round, were 64%, 56% and 51%. Despite important regional variations, the surveys showed increasing systemic pressure on anaesthetic and peri-operative services due to the need to support critical care pandemic demands. During Rounds 1 and 2, approximately one in eight anaesthetic staff were not available for anaesthetic work. Approximately one in five operating theatres were closed and activity fell in those that were open. Some mitigation was achieved by relocation of surgical activity to other locations. Approximately one-quarter of all surgical activity was lost, with paediatric and non-cancer surgery most impacted. During January 2021, the system was largely overwhelmed. Almost one-third of anaesthesia staff were unavailable, 42% of operating theatres were closed, national surgical activity reduced to less than half, including reduced cancer and emergency surgery. Redeployed anaesthesia staff increased the critical care workforce by 125%. Three-quarters of critical care units were so expanded that planned surgery could not be safely resumed. At all times, the greatest resource limitation was staff. Due to lower response rates from the most pressed regions and hospitals, these results may underestimate the true impact. These findings have important implications for understanding what has happened during the COVID-19 pandemic, planning recovery and building a system that will better respond to future waves or new epidemics.     

Critical incident reporting in the intensive care unit

Critical incident reporting was introduced into the intensive care unit (ICU) as part of the development of a quality assurance programme within our department. Over a 3-year period 281 critical incidents were reported. Factors relating to causation, detection and prevention of critical incidents were sought. Detection of a critical incident in over 50% of cases resulted from direct observation of the patient while monitoring systems accounted for a further 27%. No physiological changes were observed in 54% of critical incidents. The most common incidents reported concerned airway management and invasive lines, tubes and drains. Human error was a factor in 55% of incidents while violations of standard practice contributed to 28%. Critical incident reporting was effective in revealing latent errors in our 'system' and clarifying the role of human error in the generation of incidents. It has proven to be a useful technique to highlight problems previously undetected in our quality assurance programme. Improvements in quality of care following implementation of preventative strategies await further assessment.     

General anaesthesia in end-of-life care: extending the indications for anaesthesia beyond surgery

In this article, we describe an extension of general anaesthesia – beyond facilitating surgery – to the relief of suffering during dying. Some refractory symptoms at the end of life (pain, delirium, distress, dyspnoea) might be managed by analgesia, but in high doses, adverse effects (e.g. respiratory depression) can hasten death. Sedation may be needed for agitation or distress and can be administered as continuous deep sedation (also referred to as terminal or palliative sedation) generally using benzodiazepines. However, for some patients these interventions are not enough, and others may express a clear desire to be completely unconscious as they die. We summarise the historical background of an established practice that we refer to as ‘general anaesthesia in end-of-life care’. We discuss its contexts and some ethical and legal issues that it raises, arguing that these are largely similar issues to those already raised by continuous deep sedation. To be a valid option, general anaesthesia in end-of-life care will require a clear multidisciplinary framework and consensus practice guidelines. We see these as an impending development for which the specialty should prepare. General anaesthesia in end-of-life care raises an important debate about the possible role of anaesthesia in the relief of suffering beyond the context of surgical/diagnostic interventions.     

Chylous ascites and chylothorax due to the existence of transdiaphragmatic shunting in an adult with nephrotic syndrome.

Case Chylous ascites is a well-known complication of severe nephroticsyndrome. However, the coexistence of chylous ascites and chylothoraxis rarely reported in adult nephrotic syndrome [1]. A 66-year-old man was diagnosed with nephrotic syndrome     

Potential value of adenosine 5'-triphosphate (ATP) and adenosine in anaesthesia and intensive care medicine

Extracellular adenosine and adenosine triphosphate (ATP) areinvolved in biological processes including neurotransmission,muscle contraction, cardiac function, platelet function, vasodilatation,signal transduction and secretion in a variety of cell types.They are released from the cytoplasm of several cell types andinteract with specific purinergic receptors which are presenton the surface of many cells. This review summarizes the evidenceon the potential value and applicability of ATP (not restrictedto ATP–MgCl₂) and adenosine in the field of anaesthesiaand intensive care medicine. It focuses, in particular, on evidenceand roles in treatment of acute and chronic pain and in sepsis.Based on the evidence from animal and clinical studies performedduring the last 20 years, ATP could provide a valuable additionto the therapeutic options in anaesthesia and intensive caremedicine. It may have particular roles in pain management, modulationof haemodynamics and treatment of shock.     

Current treatment practices of venous thromboembolism in children admitted to pediatric intensive care units

Objective: To describe current treatment practices of VTE in patients admitted to a pediatric intensive care unit (PICU) and compare these practices to published guidelines. Background: While the incidence of VTE is increasing, current treatment practices of VTE in patients admitted to PICUs are not known. Methods: This multicenter, prospective, observational study enrolled patients with confirmed VTE admitted to 11 PICUs over a rolling 6‐month study period. Treatment data were collected and analyzed. Results: Sixty‐six VTEs occurred in 6653 patients. Empiric treatment for VTE was initiated in 30% prior to VTE confirmation, and children with cyanotic heart disease were 15.7 times more like to receive empiric therapy. Overall, 78% received systemic anticoagulation, 8% treated with only catheter‐based interventions, and 13% of VTE were not treated. Seven patients (11%) underwent systemic fibrinolysis; more commonly in neonates (23%) vs children (5%). Surgical and interventional procedures were performed on 4 patients. The American College of Chest Physicians recommendations were incompletely followed. Only 28% of the 32 cases treated with low molecular weight heparin titrated dosing to a goal anti‐FXa level 0.5–1. Five of the 15 cases treated with unfractionated heparin titrated dosing to aPTT 60–90, and one case did not use goal‐directed therapy. Conclusions: Confirmed VTEs in patients admitted to PICUs are most frequently treated with systemic anticoagulation; however, more intensive treatments such as systemic thrombolysis and surgical or interventional procedures are not uncommon in this critically ill population. Current practices deviate from the published antithrombotic guidelines developed for the general pediatric population.     

Patient satisfaction with anaesthesia care: development of a psychometric questionnaire and benchmarking among six hospitals in Switzerland and Austria

Background. We describe the development and comparison of apsychometric questionnaire on patient satisfaction with anaesthesiacare among six hospitals. Methods. We used a rigorous protocol: generation of items, constructionof the pilot questionnaire, pilot study, statistical analysis(construct validity, factor analysis, reliability analysis),compilation of the final questionnaire, main study, repeatedanalysis of construct validity and reliability. We comparedthe mean total problem score and the scores for the dimensions:‘Information/Involvement in decision-making’, and‘Continuity of personal care by anaesthetist’. Theinfluence of potential confounding variables was tested (multiplelinear regression). Results. The average problem score from all hospitals was 18.6%.Most problems are mentioned in the dimensions ‘Information/Involvementin decision-making’ (mean problem score: 30.9%) and ‘Continuityof personal care by anaesthetist’ (mean problem score:32.2%). The overall assessment of the quality of anaesthesiacare was good to excellent in 98.7% of cases. The most importantdimension was ‘Information/Involvement in decision-making’.The mean total problem score was significantly lower for twohospitals than the total mean for all hospitals (significantlyhigher at two hospitals) (P<0.05). Amongst the confoundingvariables considered, age, sex, subjective state of health,type of anaesthesia and level of education had an influenceon the total problem score and the two dimensions mentioned.There were only marginal differences with and without the influenceof the confounding variables for the different hospitals. Conclusions. A psychometric questionnaire on patient satisfactionwith anaesthesia care must cover areas such as patient information,involvement in decision-making, and contact with the anaesthetist.The assessment using summed scores for dimensions is more informativethan a global summed rating. There were significant differencesbetween hospitals. Moreover, the high problem scores indicatea great potential for improvement at all hospitals. Br J Anaesth 2002; 89: 863–72     

Futility and inappropriate care in pediatric intensive care: a cross-sectional survey

BACKGROUND: Over recent years, there have been increasing concerns regarding an increase in the number of futile and inappropriate admissions to pediatric intensive care units (PICUs) in the United Kingdom (UK). METHODS: A prospective cross-sectional survey was carried out using a data collection form distributed by mail to the directors of all PICUs in the UK. Respondents were asked to give details of all patients on their unit on a specific day including age, reason for admission and any preexisting medical conditions. An assessment was made by respondents of whether the care being provided in each case was, in their opinion, appropriate, futile or inappropriate according to standard definitions. RESULTS: We received responses from 21 units (68%) who reported the details of 111 patients. Care was felt to be appropriate in 88 of these cases (79%), futile in nine cases (8%) and inappropriate in 14 cases (13%). Futile cases were most commonly admitted with respiratory failure and all had preexisting medical conditions, most commonly developmental delay. Where care was felt to be inappropriate, respiratory failure was again the most common reason for admission and all had a preexisting medical condition, most commonly cardiovascular disease. CONCLUSIONS: The care being provided in 21% of the PICU cases, described in this study, was felt to be either futile or inappropriate by the directors of those units. There is an urgent need to, accurately, establish the resource consumption associated with these patients and to establish a standard approach to futility and inappropriate care in PICU in the UK.     

Criteria for intensive care unit admission and the assessment of illness severity

Critical care expansion in the UK has increased in recent years, reflecting increased demand, yet bed occupancy remains high and there are significant difficulties in matching supply and demand. Expansion of ICU services outside the walls of critical care has involved the development of complex multidisciplinary outreach services who exist to support ward teams in caring for individuals who are critically unwell or have recently been stepped down from higher levels of care; there is increased evidence of their effectiveness in reducing mortality and preventing unexpected deterioration. Discharge of patients from critical care is also an area of controversy with conflicting evidence of increased mortality rates for those discharged prematurely or out-of-hours. Careful planning is involved with appropriate post-ICU care is critical to avoiding poor outcomes. ICU scoring systems allow comparison of outcomes between individual units and facilitate research but are unhelpful in predicting outcome for individual patients. Deciding which patients not to admit to ICU are frequently the most difficult decisions facing critical care staff. Many patients previously considered inappropriate for organ support may now be admitted pre-determined limits of treatment or to facilitate complex palliative care needs.